guide to cultural competence in the curriculum

A Guide to Cultural

Competence in the

Curriculum

Physical Therapy

Karen J. Panzarella and Mary A. Matteliano

John Stone and Mary A. Matteliano, Series Editors

Copyright © 2008 by the Center for International Rehabilitation Research Information and Exchange (CIRRIE).

All rights reserved. Printed in the United States of America.

No part of this publication may be reproduced or distributed in any form or by any means, or stored in a database or retrieval system without the prior written permission of the publisher, except as permitted under the United States Copyright Act of 1976.

Center for International Rehabilitation Research Information and Exchange (CIRRIE)

515 Kimball Tower

State University of New York, University at Buffalo Buffalo, NY 14214

Phone: (716) 829-6739 Fax: (716) 829-3217

E-mail: ub-cirrie@buffalo.edu Web: http://cirrie.buffalo.edu

This publication of the Center for International Rehabilitation Research

Information and Exchange is supported by funds received from the National Institute on Disability and Rehabilitation Research of the U.S. Department of Education under grant number H133A050008. The opinions contained in this publication are those of the authors and do not necessarily reflect those of CIRRIE or the Department of Education.

A GUIDE TO CULTURAL COMPETENCE IN THE CURRICULUM:

Physical Therapy

Table of Contents

Preface... i

Purpose of this Guide... i

Philosophy and Approach ... i

How to Use this Guide... iii

References... iii

About the Authors... iv

Acknowledgements... v

Part I: Mary Matteliano Transdisciplinary Instruction for Cultural Competence ... 1

Introduction... 1

Implementation of the Campina-Bacote Model into Curriculum Design... 2

Objective 1: Students will Improve their Cultural Awareness ... 2

Objective 2: Improve Student Knowledge of Diverse Cultures and Practices ... 4

Objective 3: Improve the Student’s Skill in the Assessment of Clients from Diverse Cultures and Practices... 6

Objective 4: Improve the Student’s Ability to Develop Treatment Plans for Clients and Students from Diverse Cultures ... 8

Objective 5: Students will Develop the Desire for Cultural Competency and Understand that it is a Life-Long Process ... 9

References... 10

Appendix A: Cultural Competence Classroom Activities ... 14

Activities ... 14

Appendix B: Website Resources ... 17

Appendix C: Self -Tests and Questionnaires ... 18

Appendix D: Case Studies ... 19

Appendix E: Kleinman’s Eight Questions to Assess the Patient’s Perspectives ... 30

Part II: Karen J. Panzarella Cultural Competence in the Physical Therapy Curriculum... 31

Introduction... 31

Implementation of Cultural Competence into the Physical Therapy Curriculum ... 34

Teaching Material ... 35

Examination ... 38

Evaluation ... 40

Prognosis... 42

Intervention ... 43

Service Learning/ Community Based Projects ... 44

A Day in the Life of… ... 44

Outcomes ... 47

Clinical Experiences ... 48

Assessment of Cultural Competence ... 49

References... 51

APPENDIX A: Reflective Paper ... 55

APPENDIX B: Health BELIEF™ Instrument Attitudes Survey... 56

APPENDIX C: Communicating Between Cultures... 57

APPENDIX D: DPT Clinical Case Outline... 58

APPENDIX E: Case Presentation... 59

Preface

Purpose of this Guide

This curriculum guide has been prepared by the Center for International Rehabilitation Research Information and Exchange (CIRRIE) under a grant from the National Institute for Disability and Rehabilitation Research. Its purpose is to provide a resource that will assist faculty in physical therapy programs to integrate cultural competency education throughout their curriculum. CIRRIE’s current work with pre-service university training, complements previous CIRRIE publications designed primarily for in-service training, most notably a 12-volume monograph series, The Rehabilitation Service Provider’s Guide to the Cultures of the Foreign Born

(CIRRIE, 2001-2003), and Culture and Disability: Providing Culturally Competent Services, a book that summarized the series (Stone, 2005). Because of CIRRIE’s funding mandate from the National Institute for Disability and Rehabilitation Research, its focus in the area of cultural competency is on the cultures of persons who have come to the US from other countries. Consequently, the primary focus of this guide is on the cultures of recent immigrant groups, rather than US-born persons. Cultural competency education should certainly address issues related to US-born minorities and Dr. Panzarella addresses her activities to both recent immigrants and US-born persons from a variety of cultural backgrounds.

Philosophy and Approach

This Guide is a curriculum guide. Its objective is to provide a resource to faculty who wish to include or strengthen cultural competency education in their program and courses. Certain limitations are inherent in all curriculum guides. While there are certain common elements or competencies in most professional programs, there are also variations among different

institutions in how these are organized into specific courses. Moreover, even courses that have similar objectives may use different titles. We have attempted to provide material that could be included in most physical therapy programs, regardless of their specific curriculum structure. Its purpose is to enhance existing curricula by making available to instructors resources, case studies, and activities. This material can be adapted by the instructor as needed, in courses that are specific to cultural competence, or infused into other courses in the curriculum.

At the university level the CIRRIE approach to cultural competency education includes four main principles.

1. Integration of cultural competency into existing courses, rather than creation of new courses Although the academic credentialing standards for programs in the rehabilitation professions now require cultural competence, the curricula of most programs are already overloaded. This makes it difficult to add new courses and as a consequence, content involving cultural

competence usually becomes incorporated into existing courses retrospectively and in small doses. More importantly, a separate course on cultural competence can make the topic appear to students as isolated from the “real” set of professional skills that they are required to master. Students may consider it an interesting topic but one of little practical importance. Moreover, by

separating cultural competence from courses that develop practice skills, it becomes abstract and difficult to relate to practice.

Another reason for integrating cultural competence into existing courses is that students have an opportunity to see its implications and apply its principles in a variety of contexts. They also see that it is not just a special interest of one faculty member but an integral part of many aspects of their future practice that is supported and embraced by all faculty. When it reappears in their coursework each semester, their knowledge, attitudes, and skills in this area develop and deepen. The CIRRIE curriculum development effort has identified specific types of courses in the

physical therapy curriculum where cultural competence may be most relevant, and we have identified or developed activities and materials that are appropriate across the curriculum.

2. Development of cultural competence education that is profession-specific, rather than generic CIRRIE’s prior experience with providing cultural competency workshops for in-service training strongly suggests that an off-the-shelf generic approach is less effective than training that is specific to the profession in which the competence is to be applied. Generic training must be understandable by all rehabilitation professions, so examples, terminology, and concepts that are specific to one profession must be avoided. As a result, cultural competence becomes more abstract. With profession-specific training, students are better able to see the relevance and applicability to their profession, not as something outside its mainstream. Consequently,

CIRRIE’s approach is to work with faculty from each profession to analyze their curriculum and incorporate cultural competence into it in ways that seem most relevant to that profession.

3. Multi-disciplinary case studies

Although CIRRIE’s general approach is profession-specific, we have found that studies

developed in one program can sometimes be adapted for use in other programs. For example, a case scenario developed for a course in physical therapy may be useful in courses in

occupational therapy, speech therapy, or rehabilitation counseling. The general facts of the case may be presented to students from each program, but many of the problems, questions and assignments related to the case may be different for each of the professions. The use of common case studies provides an opportunity to analyze cultural factors from a multi-disciplinary

perspective, which is often the type of setting in which rehabilitation is practiced. 4. Making materials available to instructors

Most instructors realize the need for the infusion of culture into their curricula, but they may be reticent to incorporate culture into their courses if the burden of creating new materials is added to their normal course preparation. CIRRIE has approached this dilemma through specific strategies to allow instructors easy access to cultural content. Hence this guide was written. These materials are also available online at http://cirrie.buffalo.edu/curriculum/. The website was created to organize cultural materials into inter-disciplinary and discipline-specific assignments, case studies, lectures, reference materials, and classroom activities. This information will be expanded and revised based on feedback from users in universities nation-wide.

How to Use this Guide

Curriculum committees and other faculty groups may wish to consult this guide to examine the ways that cultural competency can be infused across a curriculum and identify ways in which this approach may be adapted to the specific context of their program.

Individual course instructors can identify the sections of this guide that relate most closely to the courses they teach. They can then see how others have included cultural competency in such courses. The resources that are suggested in the guide may be seen as a menu from which instructors can select those that fit their course and their teaching style.

Prior to the main portion of this guide that pertains specifically to physical therapy, we have included a section that presents suggestions and resources that are generic in nature and could be used in any of the rehabilitation professions.

We hope that this guide will be useful to those who are committed to strengthening this aspect of our professional programs in rehabilitation. We also understand that many institutions have created or identified resources that are not found in this guide. We welcome your comments and suggestions to increase the usefulness of future versions of this guide.

John Stone PhD,

Director, Center for International Rehabilitation Research Information and Exchange University at Buffalo

References

Stone, J. (Ed.). (2005). Culture and disability: Providing culturally competent services. Thousand Oaks, CA: Sage Publications.

About the Authors

Dr. Karen Panzarella holds a bachelor's degree in physical therapy, a master's degree in exercise science and a PhD in Educational Psychology all from the University at Buffalo where she is the Director of Clinical Education for the Doctor of Physical Therapy program. She instructs courses to physical therapy students in case management, professional development and pediatric physical therapy. She has twenty years experience as a clinician and over ten years as an educator. Her research focuses on assessing student's clinical competence through the use of standardized patients. She strives to facilitate the transition from the academic to clinic

environment through clinical and cultural competence.

Mary Matteliano, MS, OTR/L, has over 20 years of rehabilitation experience in the area of adult physical disabilities. She has been a clinical assistant professor in the Department of Rehabilitation Science at the University at Buffalo since 1999. In addition, she is the project director for “Cultural Competence in the Curriculum” for four rehabilitation programs. This is a NIDDR funded project through the Center for International Rehabilitation Research Information and Exchange (CIRRIE). Ms. Matteliano has also participated in and co-directed the study abroad program, Health in Brazil, in 2004 and again in 2006. She is currently pursuing her PhD in Sociology; her research explores the provision of culturally competent health care services to those who are from underserved groups.

Acknowledgements

Acknowledgements: Special thanks to Dr. Ronnie Leavitt who reviewed this curriculum guide and provided insightful comments and suggestions. Dr. Leavitt is a licensed physical therapist. Her advanced degrees in Public Health and Medical Anthropology have proved a focus for her interest. She has been involved in a variety of community and public health arenas both

nationally and internationally. Her expertise is in cultural competence as well as the development of community based rehabilitation in developing nations. Additionally, we would like to thank Dr. Rosemary Lubinski and Marcia E. Daumen for their assistance with proofreading, editing, and overview of the general content of this guide.

Part I: Transdisciplinary Instruction for Cultural Competence

Mary A Matteliano, MS, OTR/L, Project Director of Culture in the Curriculum, CIRRIE

Introduction

Rehabilitation services for persons with disabilities are provided in a variety of settings including medical facilities, schools, and the community. The recipients of these services are referred to as patients, students, clients, and consumers, depending on the setting. Henceforth, for the purpose of this guide, we will refer to the recipients of services as clients and students. In all settings, the team approach is valued, and the client or student benefits when each discipline is able to focus on its area of expertise in a collaborative manner. It is not unusual for clients or students to receive therapy from a variety of professionals during their course of treatment. In fact, a client or student may receive some combination of occupational therapy, physical therapy,

rehabilitation counseling, and speech-language therapy simultaneously. Additionally, rehabilitation professionals frequently request consults from other professionals and ask for another discipline’s involvement in a case. As a result of these frequent interactions among rehabilitation professionals, a team approach develops in which each provider recognizes and often supplements the unique role of other professionals. Likewise, rehabilitation professionals learn from each other in these settings and are provided with opportunities to appreciate their commonalities. Therefore, it seems fitting that CIRRIE create not only guides that are discipline specific, but also transdisciplinary and foundational information for use in all four programs. By providing general content, the expressed needs for cultural competence education can be

transferred across rehabilitation programs and serve to unify this intent. With this in mind, the transdisciplinary section of this guide was written to provide an introduction to cultural

competence instruction for occupational therapy, physical therapy, rehabilitation counseling, and speech-language therapy programs.

Rehabilitation disciplines use various frameworks and models of service provision that are specific to their practice. A conceptual framework that shows utility for all rehabilitation programs is the International Classification of Functioning, Disability and Health (ICF) (World Health Organization [WHO], 2001). The ICF can be used by rehabilitation professionals to organize and identify relevant domains for assessment, treatment, and evaluation of outcomes (Reed et al., 2005; Rentsch et al., 2003). It also provides a common language for health care providers, thereby enhancing communication among disciplines (Rentsch et al., 2003). By examining the ICF and its classification system, we can further understand the areas of concern that impact the provision of culturally competent rehabilitation services. The ICF guides

rehabilitation specialists in the assessment process by providing a framework that addresses client or student needs beyond the impairment level, thus establishing their capacity to perform within the natural environment (Occupational Therapy Practice Framework, 2002). Contextual considerations, the external or internal influences on the client or student, impact the

rehabilitation process and must be addressed. For example, external contextual influences may include the individual’s immediate environment as well as cultural and societal influences. Internal influences are more personal in nature and include the individual’s gender, race,

a framework that addresses individuals’ performance capacity within the context of their personal and external environment. By understanding this, rehabilitation professionals will improve their ability to address the influence of culture on client or student performance. In the next section we will examine a model that will be used to specifically guide the infusion of cultural competence into the curriculum for rehabilitation programs.

Although there are several models to choose from that can be used to guide curriculum planning, we have chosen the Campinha-Bacote model as a guide for teaching cultural competency to students who are enrolled in rehabilitation programs (Campinha-Bacote, 2002). According to this model, achieving cultural competence is a developmental process, not a onetime event. The

Campinha-Bacote model (2002) consists of five constructs: (1) cultural awareness, (2) cultural knowledge, (3) cultural skill, (4) cultural encounters, and (5) cultural desire. These constructs are intertwined; cultural desire is the foundation of this process and provides the energy that is needed to persevere on this journey (Campinha-Bacote, 2002). Cultural awareness, the ability to understand one’s own culture and perspective as well as stereotypes and misconceptions

regarding other cultures, is a first step (Campinha-Bacote, 2002; Hunt & Swiggum, 2007). The development of cultural knowledge can be introduced and explored throughout the curriculum, both in courses that are general as well as courses that teach specific therapeutic skills. Cultural skills, the ability to evaluate a client or student and develop a therapeutic treatment plan, build on the foundations of cultural awareness and knowledge. Courses that emphasize clinical and

educational skills can be used to help students develop a skill set that will address the unique needs of the individual. Cultural encounters can be dispersed throughout the curriculum, with the emphasis on the application of practice skills, as the student advances in the program.

Implementation of the Campina-Bacote Model into Curriculum Design

The next section of the guide is organized into five objectives that reflect the Campinha-Bacote model for achieving cultural competency. The objectives are further divided into specific goals along with suggestions, activities, and resources to achieve the stated objective.

Objective 1: Students will Improve their Cultural Awareness

1a. Students will demonstrate the ability to examine and explore one’s own culture (including family background and professional program).

1b. Students will identify stereotypes, biases, and belief and value systems that are representative of the dominant culture in the United States.

1c.Students will demonstrate an understanding of how one’s own biases and belief system may subtly influence the provision of rehabilitation or educational services and lead to cultural imposition.

In our experience, we have found that courses that emphasize communication and therapeutic interaction offer opportunities for exploration and understanding of one’s own culture. These courses are usually taught to students prior to acceptance into a professional program or during the first year. These introductory courses will sensitize students by providing information that

emphasize a continuum of cultural competence that is threaded throughout the curriculum (Campinha-Bacote, 2002; Kripaiani, Bussey-Jones, Katz, & Genao, 2006). Assignments that are specific to cultural awareness may include a class exercise in which students write about their own ethnicity/racial background. This leads to a class discussion about cultural awareness, stereotyping, and variations among cultures. Several exercises may be used within and outside of the classroom to assist students in improving their cultural awareness. They may be worked on independently or in small groups. Examples of classroom activities that may be adapted depending on the program are included in Appendix A.

Students may benefit from taking the “Implicit Association Tests” online and discussing the results in class. Project Implicit is a collaborative research effort among researchers from

Harvard University, University of Virginia, and the University of Washington. There are several exercises offered on this website, and the general purpose is to elicit thoughts and feelings that are outside of our conscious control. Those who participate in these exercises are provided with a safe and secure virtual environment in which to explore their feelings, attitudes, and preferences toward ethnic groups, race, and religion. The outcome of this exercise is for students to

understand that they may have an unconscious preference for a specific race, skin tone, religious group, or ethnic group. Students are provided with the opportunity to understand innate and unconscious attitudes that might influence their decision making ability in a rehabilitation setting. Refer to Appendix B for the Project Implicit (2007) website.

The Village of 100 activity takes about 10 minutes to complete and will also lead into some good classroom discussion (Meadows, 2005). Students must imagine that if the Earth’s population was shrunk to 100 persons what the representation of certain racial/ethnic groups would be like in areas that include religious representation, sexual orientation, literacy, wealth, education, and living conditions. Many students are not aware of the privilege they have experienced by living in the US and are enlightened once they examine the rates of poverty and general deprivation that are experienced by the global community. Again see Appendix B for the Village of 100 website.

Many readers may already be familiar with the body ritual among the Nacirema vignette, but we have found that it continues to facilitate self-reflection among students (American

Anthropological Association, 1956). Nacirema is American spelled backwards, and this narrative describes the daily rituals of American life from an outsider’s perspective. Many of our

commonly accepted practices seem very strange when seen through an outsider’s lens. The purpose of this exercise is to help students understand that although the customs and rituals of persons from other cultures may seem strange, our customs and rituals may also appear odd. Bonder, Martin and Miracle (2002) have concluded that an ethnographic approach, such as the one used in the Nacirema vignette, helps students to gain a different perspective on their culture. Appendix B details information on the Nacirema website.

Self-assessment questionnaires and surveys encourage student self-reflection and lead to group discussions and the development of cultural awareness, cultural sensitivity, and

appreciation for diversity (Spence-Cagle, 2006). Several activities that enhance student self-awareness include the Self-test Questionnaire: Assessing Transcultural Communication Goals, the Cultural Values Questionnaire (Luckman, 2000) and the Multicultural Sensitivity Scale

(MSS) (Jibaia, Sebastian, Kingery, & Holcomb, 2000) (Appendix C). The Self-test

Questionnaire, Assessing Transcultural Communication Goals, was developed to help students understand their knowledge and comfort level with various individuals and groups that reside in the US. Some examples of groups that are represented on this self-test are: Native Americans, Mexican Americans, prostitutes, the elderly, and persons with cancer. The objective of the self-test is to facilitate discussion and develop insight among students on their preferences and knowledge about persons who are different from themselves.

The Cultural Values Questionnaire asks students to rate their agreement with a series of

statements. Some of the statements demonstrate values that reflect mainstream society in the US including timeliness, stoicism, individuality, while other statements reflect values that might be preferred by societies that value interdependence over independence. This exercise can be used to facilitate discussion among students on values that may be preferred by the rehabilitation provider. Students can develop strategies that tailor rehabilitation programs for persons whose values are different from the provider or the institutions that provide services.

The Multicultural Sensitivity Scale consists of 21 statements, and students rate their agreement with the statements on a scale of one to six. The statements ask students to rate their comfort level and willingness to accept various cultures that are different from their own. This scale can be taken on an individual basis and then used to enhance classroom discussion on students’ ability to accept, interact, and feel comfortable with clients or students who are from diverse backgrounds.

Objective 2: Improve Student Knowledge of Diverse Cultures and Practices

2a.Students will understand various health, education, and disability belief systems and practices.

2b.Students will familiarize themselves with disability prevalence and risk factors among different racial/ethnic groups.

2c.Students will understand and identify racial and ethnic disparities in rehabilitation and educational services in the United States.

2d.Students will recognize and understand various cultural worldviews and disability beliefs and explanatory models.

2e.Students will identify instances when religious or traditional views may influence the client’s participation in rehabilitation and educational regimens.

After general and self-awareness exercises, students can progress to the development of knowledge about other cultures. Encounters in non-traditional settings offer opportunities for students to try out new skills with clients from diverse cultures with guidance and feedback from their instructors (Luckman, 2000; Parnell & Paulanka, 2003). Students may increase their

knowledge about different cultures by visiting ethnically diverse neighborhoods, exploring ethnic supermarkets and restaurants, attending religious services that are different from their own

community centers (Jeffreys, 2006; Luckman, 2000; Hunt & Swiggum, 2007). These

introductory observational opportunities should be set-up as non-threatening encounters that lead to self-reflection through written assignments and group discussions (Hunt & Swiggum, 2007). A by-product of this self-reflective process is the development of an appreciation for ethnic diversity, religious practices, food preferences, family values, health beliefs, and neighborhood community programs (Griswold, Zayas, Kernan, & Wagner, 2007). Furthermore, encounters in ethnically and racially diverse settings allow students to develop confidence when encountering clients from diverse backgrounds (Hunt & Swiggum, 2007). However, both the instructor and students must keep in mind that one or two visits to a “different” neighborhood merely

introduces students to the most obvious aspects of a cultural community. Only living and

interacting with members of a community on a daily or long term basis truly opens students to a culture.

The acquisition of knowledge about specific cultures can be approached in several ways. Students can access the Center for International Rehabilitation Research Information and Exchange (CIRRIE) on-line monograph series (CIRRIE, 2003). The monographs focus on the top ten countries of origin of the foreign-born population in the US, according to the US Census Bureau: Mexico, China, Philippines, India, Vietnam, Dominican Republic, Korea, El Salvador, Jamaica, Haiti, and Cuba. There is an additional monograph on the Muslim perspective.

Assignments can be provided using a case study format with the monograph series as a resource.

Prior to clinical encounters, the use of case studies is also helpful in developing clinical decision making, self-reflection, and examining ethical dilemmas (Spence-Cagle, 2006). The case study format has been used to help students process, problem-solve, and apply strategies that will enhance their knowledge of culturally competent service (Lattanzi & Purnell, 2006). Therefore, case studies encourage the examination of the professional’s explanatory model and the client’s explanation of their illness experience. Explanatory models are the perceptions and beliefs that rehabilitation providers, clients, students, and their families construct about illness and disability (Kleinman, 1988; McElroy & Jezewski, 2000). They are cognitive and emotional responses based on cultural experiences (Kleinman, 1988). Therefore, explanatory models are not always transparently logical, and if the rehabilitation provider’s communication skills are based on their own perspective, the client or student may experience discrimination. In addition, through the case study format, students can be encouraged to develop culture-brokering skills that further expand their appreciation of various belief systems (Kleinman, 1988; Jezewski & Sotnik, 2005). Examples of case studies and case scenario assignments, that are applicable across disciplines, are found in Appendix D.

We refer to the culture-brokering model in this guide because it has been shown to be useful in training rehabilitation personnel in identifying and devising solutions for culturally related problems. The culture-brokering model was adapted by CIRRIE for rehabilitation systems, and a training workshop was designed based on the model (Jezewski & Sotnick, 2005). The model has three stages: (1) problem identification, (2) intervention strategies, and (3) outcomes. Problem identification includes a perception of a conflict or breakdown in communication. Intervention strategies include establishing trust and rapport and maintaining connections. Stage three is

evaluating outcomes, both successful or unsuccessful. Success is achieved if connections are established between consumers and the rehabilitation system, as well as across systems. What

makes this brokering model a culture-brokering model is a fourth component, Intervening Conditions. These are culturally based factors that must be considered at all three stages:

analyzing the problem, devising appropriate strategies, and evaluating outcomes. The intervening conditions include a variety of factors including type of disability, communication, age of the client or student, cultural sensitivity, time, cultural background, power or powerlessness,

economics, bureaucracy, politics, network, and stigma. The model is not a set of rules or steps to follow. Rather, it is a conceptual framework that can guide the service provider in analyzing problems and devising culturally appropriate solutions. For a more detailed description of this

culture-brokering model, including its applications to case studies, see Jezewski and Sotnick (2005).

When implementing the culture-brokering model, students must understand that health and education seeking behaviors are shaped by the individual’s cultural context, and most cultural groups are heterogeneous (Rorie, Pain & Barger, 1996; Menjívar, 2006). Caution within training programs should be exercised. Knowledge of various cultures and their practices, if not

considered within the context of individuals and their unique circumstances, can result in destructive stereotyping. Stereotypes that are associated with particular cultures may affect the provision of rehabilitation services in adverse ways. Therefore, although knowledge of cultures is important, students must refrain from stereotyping and be aware constantly of the

heterogeneity of persons within cultural groups (Campinha-Bacote, 2002; Juckett, 2005). There are many reasons for intra-cultural variations including the individual’s level of education, socioeconomic status, reasons for immigration, and regional and local differences within the country of origin. In addition, the process of immigration is complex. Immigration may be voluntary, or it may be a decision based on persecution or economic hardship. This affects the immigrant’s ability to improve social status and assimilate into a new culture. Assimilation is also affected by the human, cultural, social, and economic capital that accompanies the immigrant into the destination country (Alba & Nee, 2003).

Objective 3: Improve the Student’s Skill in the Assessment of Clients from Diverse Cultures and Practices

3a. The student will learn to determine client and student needs within the context of their culture.

3b.The student will become familiar with and demonstrate the use of assessments that respect and explore client and student culture and the impact it has on their disability. 3c.The student will identify culturally biased assessments and demonstrate the ability to

modify or adapt the assessment to fit client and student needs.

3d. The student will utilize the client’s family and/or extended family in the assessment process, if designated by the client or student.

Students’ ability to develop cultural skill depends on the first two constructs that were explored, awareness and knowledge. Skill development overlaps with practice and cultural encounters. Students in rehabilitation professions must understand how to use the interview process to

formulate relevant treatment options for their client. Students must then be provided with clinical encounters that allow for the development of skill when working with clients or students from diverse cultures (Campinha-Bacote, 2002). Neighborhood community centers, schools, and adult day care facilities are several examples of potential sites that may offer diversity and contribute to students’ fieldwork experiences (Griswold et al., 2007; Hunt & Swiggum, 2007). Through observations and clinical encounters, students develop and expand on their interviewing techniques, including the use of interpreters, the ability to become flexible with traditional assessment procedures, and an appreciation for the client’s narrative (Hunt & Swiggum, 2007). The personal narrative, listening to clients or students tell their story, is best learned through clinical encounters (Griswold et al., 2007; Kripaiani et al., 2006). Students must learn when to leave aside traditional assessment procedures and encourage interviewees to describe their illness experience in their own words (Griswold et al., 2007; Kleinman, 1997). The person’s view of disability does not necessarily surface when using standardized assessments that are popular among professionals (Ayonrinde, 2003; Becker, Beyene, Newsom, & Rodgers, 1998). Another approach is to adapt current assessment/ evaluation methods and identify culturally relevant assessments within each rehabilitation field.

To understand the participant’s perception of disability, interviewers can use a semi-structured format that incorporates the ethnographic principles of open ended questions (Babbie, 2004). Changes and adaptations can be made to the interview questions, according to the interviewee’s responses. This format may facilitate the emergence of the interviewee’s personal story. Students may also use a modified version of Kleinman’s eight questions and incorporate this into their interview schedule. The questions may help providers understand clients by asking for a

description of what their disability means to them (Kleinman, Eisenberg & Good, 1978). Caution should be used when incorporating these questions into the interview schedule since some

individuals may not choose to discuss their disability experience in this manner. See Appendix E for Kleinman’s eight questions.

There are many factors that should be considered by rehabilitation providers in culturally diverse settings, and a number of these should be elaborated on and examined in depth in the academic setting. Examples are:

 Cultures vary on their expectation of formality in clinical situations. For example, Asian Americans may be more formal, especially elders (Liu, 2005; Wells & Black, 2000). Thus, clinical encounters should reflect this style of interaction.

 Some cultural groups communicate in ways that are different from the direct style of communication favored by Americans. For example, some cultures communicate in a less direct manner and rely on the context and subtleties in style to get their message across (Jezewski & Sotnik, 2005).

 Many Latin and Middle Eastern cultures do not value time in the same way as Americans. They may prioritize personal commitments over time commitments in business encounters or in adherence to clinical appointments (Sotnik & Jezewski, 2005).

 Some cultures, for example those of the Middle East, expect long greetings and inquiries about family members and their states of health. They may also expect offerings of food and drink (Ahmad, Alsharif, & Royeen, 2006).

 The assistance of an interpreter should be used to facilitate communication; however, family members should not be used in this role, if possible. The dual role of family member and interpreter may cause conflict, and valuable information may be omitted (Dyck, 1992). Clinicians must become familiar with techniques on how to use an interpreter and seek interpreters who are well-trained and artful in the subtle negotiation process between client and provider (Ayonrinde, 2003).

 In some cultures, such as the Hmong, a husband or oldest son will make decisions for all members of the clan. The individual’s wishes are deferred to a designated member in the clan (Leonard & Plotnikoff, 2000). Thus, it is important to ascertain who is the primary decision maker in the family and enlist his or her help in the diagnostic and rehabilitation process.

 All clients have a history prior to their disability. Providers must balance clients’ history, present condition, and potential for the future. This process is best accomplished through the dual contributions of provider and client (Fleming, 1991).

 Certain occupations and daily activities may be defined in ways that are not familiar to the provider. For example, some cultures prioritize certain daily activities (e.g. hygiene, dressing, and eating) whereas others do not (Zemke & Clark, 1996).

 Assessment tools that evaluate individual differences and preferences, including the personal narrative, should be included in the rehabilitation process (Clark, 1993).

Objective 4: Improve the Student’s Ability to Develop Treatment Plans for Clients and Students from Diverse Cultures

4a.Students will apply previously learned knowledge and skills to develop culturally competent treatment plans in medical, educational, and neighborhood community settings.

4b.Students will utilize the “Culture Brokering Model” to recognize and identify conflict that is a result of cultural beliefs and values.

4c.Students will demonstrate the ability to use strategies that result in better rehabilitation and educational services for clients and students.

4d.Students will demonstrate advocacy skills for those groups that are underrepresented in the rehabilitation and educational systems and will negotiate and network among providers to assist clients and students in achieving adequate services.

Cultural encounters allow students to apply classroom knowledge and techniques into real world settings. Students gain knowledge about different cultural backgrounds and achieve skill by learning verbal and non-verbal communication techniques. Effective learning is developed through experiences that help students become self-aware and appreciate cultural differences, thus developing acceptance and advocacy (Jeffreys, 2006). Just as students in health related curricula must fulfill fieldwork requirements to ensure that they are competent practitioners, they should also be provided with opportunities to demonstrate competence with culturally specific interactions. Provision of opportunities to gain exposure to various cultural and ethnic groups can be dispersed throughout the curriculum, at many different levels (Kripaiani et al., 2006). The progression may start with encounters that are mostly observational and progress to interactions that require formulating a plan of action, a treatment plan, or a community-based intervention. Our students have performed service work and implemented programs at refugee centers, neighborhood youth programs, international institutions, and community after school programs. As students progress through the curriculum, their cultural encounters will reflect their

acquisition of cultural competence skills (Campinha-Bacote, 2002; Griswold et al., 2007; Hunt & Swiggum, 2007).

Contextual considerations that include the individual’s process of immigration and assimilation should be incorporated into the assessment process. Several situations that are a result of

immigration may impede rehabilitation. Therefore, students should pay attention to such factors as the disruption of family support systems and social networks, post-traumatic disorders experienced by asylum seekers and refugees, and the withholding of information that characterizes undocumented immigrants’ worry about deportation (Ayonrinde, 2003). The

Culture-brokering model (Jezewski & Sotnik, 2005) can be used to demonstrate to students that treatment planning is a process of negotiation. This problem solving model will help students recognize and identify problems related to cultural preferences or beliefs, facilitate conflict resolution through the process of negotiation and mediation, and better prepare them to advocate and network on the client’s behalf.

Objective 5: Students will Develop the Desire for Cultural Competency and Understand that it is a Life-Long Process

5a.Students will develop and demonstrate the ability to empathize and care for clients and students from diverse racial/ethnic groups.

5b.Students will demonstrate flexibility, responsiveness with others, and the willingness to learn from others.

5c.Students will exhibit “cultural humility,” the ability to regard clients and students as cultural informants.

By using the Campinha-Bacote Model, it is hoped that students will develop the final construct of this model, Cultural Desire. “It has been said that people don’t care how much you know, until they first know how much you care” (Campinha-Bacote, 2002, p. 182-183). Cultural desire is a result of successful cultural encounters. Successful cultural encounters are the result of good preparation and the support and guidance offered to the student throughout the process. The student should understand that this is a life-long pursuit for the professional who has a true desire to practice in a culturally responsive manner.

Griswold et al. (2007) discuss the development of empathy and cultural humility among medical students who have participated in refugee clinics. During an encounter with an elderly

Vietnamese woman, a medical student tossed his checklist aside as the patient began to cry and tell him about the loss of her family members. The student discusses a transformation in his approach: “…I was going through the checklist…as she started to cry it shook me…I stopped the interview…as the empathy kicked in, the checklist started to fall out of my head” (Griswold et al., 2007, p.59). Students may find interviews particularly challenging with persons who have suffered grave personal loss or who have been victims of torture. They may at first meet failure because they are unable to show openness and flexibility during the initial assessment. Since these encounters may be difficult, they will need to be provided with opportunities to debrief and discuss their cases with instructors and other students. Opportunities for self-reflection regarding their feelings, as well as the needs of their clients, should be encouraged by their instructors (Griswold et al., 2007). Self efficacy, the belief that one can achieve competence in areas of practice, motivates students to overcome obstacles and embrace the learning experience (Jeffreys, 2006). It is our goal that the outgrowth of these exercises will provide students with positive cultural experiences that improve their confidence, engage their interest, develop their ability to empathize, and result in the desire to provide culturally responsive rehabilitation services across settings.

References

Alba, R., & Nee, V. (2003). Remaking the American mainstream. Cambridge: Harvard University Press.

Ahmad, O. S., Alsharif, N. Z., & Royeen, M. (2006). Arab Americans. In: M. Royeen & J. L. Crabtree (Eds.), Culture in rehabilitation (pp. 181-202). Upper Saddle River, NJ: Pearson Education Inc.

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American Occupational Therapy Association. (2002). Occupational therapy practice framework: Domain and process. American Journal of Occupational Therapy, 56, 609-639.

Ayonrinde, O. (2003). Importance of cultural sensitivity in therapeutic transactions:

Considerations for healthcare providers. Disability Management and Health Outcomes, 11(4), 234-246.

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Becker, G., Beyene, Y., Newsom, E., & Rodgers, D. (1998). Knowledge and care of chronic illness in three ethnic minority groups. Family Medicine, 30, 173-8.

Bonder, B., Martin, L., & Miracle, A.W. (2002). Culture in clinical care. Thorofare, NJ: Slack Publishers.

Campinha-Bacote, J. (2002). The process of cultural competence in the delivery of healthcare services: A model of care. Journal of Transcultural Nursing, 13(3), 181-184.

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Kantonssipital of Lucerne, Switzerland. Disability and Rehabilitation, 25(8), 411-421. Rorie, J., Paine, L. L., & Barger, M. K. 1996. Primary care for women: Cultural competence in

primary care services. Journal of Nurse-Midwifery, 4, 92-100.

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Culture and disability: providing culturally competent services (pp.15-36). Thousand Oaks, CA: Sage Publications.

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disability: providing culturally competent services. Thousand Oaks, CA: Sage Publications.

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Appendix A: Cultural Competence Classroom Activities

Many of these activities involve encouraging students to meet and interact with individuals from diverse backgrounds. While the experience is important, it is the opportunity to reflect upon the interactions and perceptions that will heighten cultural awareness. Reflection can be encouraged through journal writing, class discussion and debates, and role playing.

Activities

a. Who Am I? Students begin the process of cultural awareness by exploring their own backgrounds.

Student Assignment: Investigate your own cultural background. Try going back three

generations. Make a genealogical map of your ancestors including their country of origin, family, language(s) spoken, religion, education, occupation, and beliefs regarding health/disease,

disability, and education. Be prepared to discuss how you obtained your biographies, from whom, and the information that was omitted or obscure. Other areas that define the culture may be included such as family roles and rules, family support networks, music, food preferences and eating styles, entertainment, clothing, child rearing practices. Think about and be prepared to discuss how cultural influences have been maintained, changed, or have disappeared across generations.

b. Story Teller. Ask students to interview someone in their own family who is an especially good story teller about family life. Student Assignment: Interview an individual in your family who has a repertoire of family stories. Record the story(ies) he or she tells about your family’s history. What is the story about, and what does it reveal about your cultural, ethnic, linguistic, religious, and racial background? What did you learn from this interview that you did or did not know about your history? Ideally, this story telling activity should be audio/video taped so that it can be presented to the class.

c. Pix Share. Visual history helps students understand their cultural background. Ask students to share pictures of their family and the area in which they have lived most of their life. Student Assignment: Find family pictures across generations, if possible. Discuss how these pictures reveal your cultural, ethnic, linguistic, religious, racial background, and living environments. What did you learn from these pictures that you did not know about your family? To whom did you go for the pictures and information about their content? Discuss how the pictures are similar or different across class members.

d. Family Differences. Have students discuss how their own views on cultural issues such as family, religion, health, education, and disability differ from that of their parents or grandparents.

Student Assignment: What are your family’s views on family, religion, health, education, and disability? Compare your views on these topics with that of your parents and grandparents. Also discuss family perceptions of disability especially if there is a family member who has a

disability. What rehabilitation services did the family and individual access and to what success? How does your the family view disability and rehabilitation services?

e. I See My Community. Ask students to make a video tape of what they think best represents their individual cultural background in their home community. Student Assignment: Prepare a video and audio presentation that illustrates what you think is important about your community. Topics might include description of your physical and social neighborhood, education and health care options, transportation, language(s) spoken, icons that represent the community, arts,

schools, and assets and problems. Compare and contrast the presentations across students. f. New Arrival. Have students interview someone who has recently immigrated to the US from another country. If the individual does not speak or has limited ability in English, students should use an interpreter. Keep in mind that these are sensitive topics and not all recent immigrants may want to discuss them. Only students who are especially sensitive and grounded in cultural issues should do this assignment. Student Assignment: Interview a recent immigrant to the US on topics related to why the individual came to the US, the process and problems in coming, similarities and differences between the old and new communities in which the individual lives, and views on healthcare, education, and disability. Another important topic is the meaning and structure of family in the culture. If the immigrant does not speak English, you may need to work with an interpreter. Class discussion should also focus on several issues including (a) how the interviewer felt working with an interpreter, (b) problems in doing the interview, and (c) belief systems that emerged regarding health, education, and disability. This interview might be repeated with someone who immigrated 10+ years ago to determine how time in the US influenced perceptions of health, education, and disability.

g. Exchange. Discuss the experiences students have had to open them to other cultures; e.g. travel, having an exchange student in their home or high school, and living or working with students from other countries. Student Assignment: Through what experiences have you opened yourself to other cultures? Describe these. What did you personally gain from traveling

throughout the US or other countries or interacting with an exchange student? What issues did you face when you spent time in another country and culture? How did these issues change over time? How do you maintain contact with persons you met from another country? Compare your perceptions from before the cultural exchange, during, and now. How have your perceptions changed?

h. Getting to Know You. Encourage students to “get to know” someone from a different culture during the semester and keep a journal about the experience. Remember that visiting another community for a shopping experience will not fulfill the goal of this assignment. Student Assignment: Ask a fellow student from another culture if you might spend some time with him or her at home. Immerse yourself in another culture by participating in family and community activities, shopping in the community, and attending church, celebration, or other activities that represent the culture. You might also tutor or mentor a student from a diverse background and discuss this experience. What did you learn about the culture? What experiences were most revealing to you? How do you think you were perceived as a visitor to the community? What will you do to maintain contact with the individuals you met for this assignment?

i. Cultural Conflict. Another topic for discussion is cultural conflict. Ask students what cultural conflicts occur in their community and why. Student Assignment: What can be done to

entertainment venues reflect general American culture and how this is interpreted in various cultures in the US as well as around the world.

j. Community Visits. Have students visit a school and a hospital that are comprised primarily of those from diverse backgrounds. Student Assignment: Visit a school, hospital, or other agency that delivers rehabilitation services to children and/or adults who are from diverse backgrounds. Discuss how the facility reflects various cultural backgrounds – e.g. staff, language, type and style of delivery of services or classes, inclusion of family, programming, architecture and design, etc. What differences in quality of health care and educational services are apparent? k. Continuing Education Possibilities. Rehabilitation students need to realize that cultural competence is a “profession-long” process. Student Assignment: How can rehabilitation specialists increase or improve their cultural competency once they have completed their professional degrees? What types of continuing education programs are available through local, state, or national professional organizations? What other venues are available for continuing education regarding multicultural issues?

l. Multicultural Preparation. Caseloads in all types of rehabilitation settings reflect an increase in clients from diverse backgrounds Student Assignment: Interview a variety of rehabilitation professionals who work with multicultural populations on their caseloads regarding their academic and clinical preparation for this type of client. How well prepared were they and what have they done post graduation to improve their cultural competency? What suggestions on cultural diversity do they have for clinicians entering today’s profession?

Appendix B: Website Resources

Center for International Rehabilitation Research and Information Exchange (CIRRIE) website:

http://cirrie.buffalo.edu/monographs/index.html

The Project Implicit (2007) website:

https://implicit.harvard.edu/implicit/demo/selectatest.jsp

State of the Village Report website:

http://www.sustainer.org/dhm_archive/index.php?display_article=vn338villageed Nacirema website:

Appendix C: Self -Tests and Questionnaires

The reader may refer to the CIRRIE Cultural Competence Website

http://cirrie.buffalo.edu/curriculum/activities/index.html for information on the following questionnaires and resources:

 Self-test Questionnaire: Assessing your Transcultural Communication Goals and Basic Knowledge

Reprinted with permission from: Randall-David, E., (1989). Strategies for working with culturally diverse communities and clients. Association for the Care of Children's Health (ACCH), Bethesda MD.

 Cultural Values Questionnaire

Thiederman, S. B. (1986). Ethnocentrism: A barrier to effective health care. Nurse Practitioner, 11(8), 52-59.

 Muticultural Sensitivity Scale

Reprinted with permission from: Jibaja, M. L., Sebastian, R., Kingery, P., & Holcomb, J. D. (2000). The multicultural sensitivity of physician assistant students. Journal of Allied Health, 29(2), 79-85.

 Classroom Activities: Cultural Visit, Observation Visit, and Participant Observation Visit. Adapted with permission from: Luckman, J. (2000). Transcultural communication in healthcare. Albany, NY: Delmar Thompson Learning.

Appendix D: Case Studies

The following case studies are designed for students and readers across disciplines. One is specific to one or two professions (Study 1), some are designed for all disciplines (Study 2 and 4), and one is specific to speech-language pathology (Study 3). The case studies also differ in their design; some providing more detailed backgrounds (Study 2 and 3), others more study questions and cultural information (Study 2 and 4). Pseudonyms are used in all cases.

Case Study #1 for PT and OT: Middle Eastern Low Back Pain Patient

Background

Farideh Daei (pseudonym) is a 25 year old woman from Iran. Her physician has recommended a consult for physical therapy for low back pain. During the initial evaluation, Mr. Daei, her husband, answered all the questions directed to Farideh. When asked to rate her pain on a scale of one to ten, the husband answered, “I really don’t think her pain is that bad, you can give her a three.” The wife compliantly allowed her husband to answer all questions. The PT attempted a physical assessment of the back but had to limit her examination due to Farideh’s reluctance to disrobe. The PT was upset after the initial evaluation and was not sure how to go about helping her client’s back pain because she was unable to conduct a standard evaluation.

The physical therapist recommended a home assessment by an occupational therapist because Farideh has two children that she picks up and carries, a 2 year old and a 5 month old baby. The OT scheduled a visit to observe Farideh carry out her daily routine and made some suggestions for modifying her child care activities to protect her back. When the OT arrived at the house, she was surprised to find Mr. Daei home. He did not allow the OT any time alone with his wife and answered all questions. The OT found the situation disconcerting since she had to go through a third party in order to understand her client’s daily routine. She did not feel she was able to truly assess her client’s situation although she was able to show Farideh how to wrap the baby in a sling close to her body when carrying the infant. Farideh and Mr. Daei seemed agreeable to this modification.

Student Reading

Ahmad, O. S., Alsharif, N. Z., & Royeen, M. (2006). Arab Americans. In M. Royeen & J.L. Crabtree (Eds.), Culture in rehabilitation (pp. 181-202). Upper Saddle River, NJ: Pearson Education Inc.

Hasnain, R., Shaikh, L., & Shanawani, H. (2008) Disability and Islam: An introduction for rehabilitation and healthcareproviders. Monograph series for the Center for

International Rehabilitation Research Information and Exchange (CIRRIE), Buffalo, NY: CIRRIE.

Discussion Questions

 Do you feel angry at Mr. Daei for not allowing his wife to participate in the evaluation procedure? Why?

 What are some other examples of how gender can have a strong influence on communication between the client and clinician?

Case Study #2 for SLP, OT, and PT: Hispanic TBI Client

Background

Hernando Gonzales (pseudonym), age 63, incurred a traumatic brain injury (TBI) to the left and right frontal lobes and the left temporal lobe and broken right shoulder and leg during a car accident on March 15th of this year. Mr. Gonzales was born and resides in Mexico and was visiting his sister, Maria, for a two month vacation when the accident occurred. This was his first visit to Buffalo, NY, though he has visited Miami, Florida, and San Antonio, Texas, several times in the past 20 years. Mr. Gonzales has been a widower for 6 months and has four adult children who reside in Mexico. Mr. Gonzales completed 9th grade in Mexico and works as a security guard at an industrial site. He speaks fluent Spanish and reads and writes Spanish at about a 6th grade level. Although he has taken English emersion classes for several years and his auditory comprehension of English is good, his spoken English is limited. Reading and writing English are basic and inconsistent. He is an ardent soccer fan, enjoys Mariachi music, and attends church on a regular basis.

According to his sister, Mr. Gonzales has a history of hypertension, prostate cancer, and osteo-arthritis. He had a partial knee replacement to the right knee three years ago. He wears corrective lenses that were broken during the car accident, and during the optometric evaluation to replace his lenses, early stage bilateral cataracts were noted. Three years ago Mr. Gonzales was

diagnosed with a mild bilateral sensori-neural hearing loss during an employment hearing evaluation but refused amplification.

Following the TBI, Mr. Gonzales made good physical recovery. He received intensive occupational and physical therapy for four weeks in a medical rehabilitation unit. Therapies focused on gaining independence in activities of daily living (ADLs). Although Mr. Gonzales made marked improvement in ADLs, he continued to need prompting and reinforcement to initiate and complete activities such as dressing, grooming, and bathing. He still has some difficulties with walking and balance. Cognitive-communicative therapy was also implemented and stressed word retrieval strategies, sentence production related to ADLs, auditory

comprehension and verbal expression, and executive skills such as planning, problem solving, and self-evaluation. All therapy stressed the use of English language. Each therapist commented that Mr. Gonzales had difficulty following simple commands given in English and preferred to communicate in Spanish even though only the speech-language pathologist was somewhat fluent in Spanish. He switched between Spanish and English during most informal conversations. Mr. Gonzales enjoyed inpatient therapies but seemed to want to socialize with other patients and clinicians more than do therapy. Other patients did not understand his overtures spoken in Spanish. Mr. Gonzales became increasingly distracted and uncooperative when tasks involved speaking or understanding English. The female clinicians also noted that Mr. Gonzales

concerned about some of what they considered inappropriate comments about female patients and therapists. Continued home-care based PT, OT, and SLP therapies were recommended at time of discharge. Mr. Gonzales stated that he would like to return to his job on a part-time basis when he returns home in several months.

Mr. Gonzales’s sister, Maria Lopez (pseudonym) age 70, is a widow and resides in an apartment with her adult daughter Rose, age 36, who works as an accountant for a national hotel chain. Rose travels frequently for her employment and relies on friends and neighbors from their church to help her mother. Mrs. Lopez speaks only limited English and prefers to communicate in Spanish. Her daughter says that her mother actually understands English relatively well but is “insecure” about her spoken English skills with those outside the home. Mrs. Lopez indicated through her daughter that she does not want her brother sent to a nursing home and will provide care for him on an extended basis. Mrs. Lopez visited her brother almost daily while he was in medical rehabilitation, often bringing him herbal drinks, sweets, and prayer cards. Therapists noted that Mr. Gonzales became more passive when his sister visited, and he expected her to meet his needs. Thus, Mr. Gonzales will reside with his sister for the next three to four months to receive home care therapy before returning to Mexico. His adult children will visit intermittently to help with care but will be available on an irregular basis. Only two speak English fluently. You are the speech-language pathologist, physical therapist, or occupational therapist assigned to do home care with this patient. You do not speak Spanish fluently but know some social Spanish. Consider the following questions as you prepare to work with this client in his sister’s home.

Questions to Consider

1. In reviewing the background information, what cultural, physical, cognitive,

communication, and environmental factors would you need to take into consideration in working with this client in a home care situation?

2. How might cultural differences be confused with or compounded by other physical, cognitive, communicative, or environmental characteristics in this case? Why is it important to differentiate cultural differences from those related to the client’s other characteristics?

3. What adjustments might you make in both your assessment and intervention based on this client’s cultural and linguistic background and his traumatic brain injury?

How would you enlist the help of this client’s family, particularly his sister, to facilitate therapy? What problems might you have in working with them to enhance therapy effectiveness?

Resources for Working with Hispanic Clients

American Speech-Language-Hearing Association. (1985). Clinical management of communicatively handicapped minority language populations. ASHA, 27, 29-32.

Battle, D. (1993). Communication disorders in multicultural populations. Boston: Andover Medical Publishers.

Brice, A. et al. (1998). Serving the Hispanic population: Creative solutions for therapy. Annual Convention of the American Speech-Language-Hearing Association. Available at

http://www.asha.ucf.edu/ashasic98.html.

Centeno, J. (2005). Working with bilingual individuals with aphasia. The case of a Spanish English bilingual client. Newsletter of the ASHA Special Interest Division 14: Communication Disorders and Sciences in Culturally and Linguistically Diverse Populations. 12, 2-7.

Cheng, L. (1989). Intervention strategies: A multicultural approach. Topics in Language Disorders, 9, 84-93.

Goldstein, B. (2000). Cultural and linguistic diversity resource guide for speech-language pathologists. San Diego: Singular Publishing Group.

Kohnert, K. (2005). Cognitive-linguistic interactions in bilingual aphasia: Implications for intervention. Newsletter of the ASHA Special Interest Division 2: Neurophysiology and Neurogenic Speech and Language Disorders, 15, 9-24.

Langdon, H. (1992). The Hispanic population: Facts and figures. In H. Langdon and L. Cheng (Eds), Hispanic children and adults with communication disorders: Assessment and intervention. Gaithersburg, MD: Aspen Publishers.

Marrero, M., Golden C., and Espe-Pfiefer, P. (2002).Bilingualism, brain injury and recovery. Implications for understanding the bilingual and for therapy. Clinical Psychological Review, 22, 463-478.

Morgenstery, L., Steffen-Batey, L. et al. (2001). Barriers to acute stroke therapy and stroke prevention in Mexican Americans. Stroke,32, 1360-1364.

Ruoff, J. (2002). Cultural-linguistic considerations for speech-language pathologists in serving individuals with traumatic brain injury. Newsletter of the ASHA Special Interest Division 14: Communication Disorders and Sciences in Culturally and Linguistically Diverse Populations. 8, 2-5.

Santana-Martin, S., & Santana, F. (2005). An introduction to Mexican culture for service providers. In J.H. Stone (Ed.), Culture and disability: providing culturally competent services (pp.161-186). Thousand Oaks, CA: Sage Publications.

Case Study #3 for SLP: Korean Child with Asperger’s Syndrome

Background

David Lee (pseudonym), age five years ten months, was diagnosed recently with Asperger’s syndrome. His parents, Lisa and Adam Lee, followed the recommendation of their pediatrician,

APPENDIX A: Reflective Paper

Reflective Paper: My Cultural Awareness Scoring Guide:

Exceptional = 4 Strong = 3 Emerging = 2 Needs Work= 1

Content Exceptional Strong Emerging Needs

Work Opening paragraph clearly defines the

topic and purpose of paper in relation to assignment.

       

Purpose is clear, identifies personal cultural traditions and/or religious traditions.

       

Identifies how they are like all human beings, like some human beings and like no other human being.

       

Interpretation Exceptional Strong Emerging Needs

Work Ideas presented show complex

reasoning, well thought out.

       

The author’s “culture” is clearly defined.

       

Ideas presented show evidence of original thought from personal experiences.

       

Ideas for ways to improve the author’s awareness of cultural and religious beliefs of his or her patients are apparent.

       

Ideas presented engage the reader.        

Organization Exceptional Strong Emerging Needs

Work Ideas and concepts show a logical

development that reaches a conclusion in the final paragraph.

       

There is a clear sense of sentence structure, transitions, and verbal clarity.

       

Mechanics Exceptional Strong Emerging Needs

Work Spelling, grammar, and punctuation are

appropriate.

       

Paragraphs have an opening topic sentence and are well organized in length and structure.

       

APPENDIX B: Health BELIEF™ Instrument Attitudes Survey

IPC MS 1 Survey

Give YOUR opinion for each item using the responses below. Bubble in your responses using the SCANTRON sheet provided.

Strongly Disagree Moderately Disagree

Mildly Disagree Mildly Agree Moderately Agree

Strongly Agree

1 2 3 4 5 6

1) Physicians should ask patients for their opinions about their illnesses or problems. 2) It is important to know patients’ points of view for the purpose of diagnosis.

3) Patients may lose confidence in the physician if the physician asks their opinion about their illness or problem.

4) Understanding patients’ opinions about their illnesses helps physicians reach the correct diagnosis. 5) A physician can give excellent care without knowing patients’ opinions about their illnesses or problems. 6) Understanding patients’ opinions about their illnesses helps physicians provide better care.

7) A physician can give excellent health care without knowing a patient’s understanding of his or her illness. 8) Physicians should ask their patients what they believe is the cause of their problem/illness.

9) A physician should learn about their patients’ cultural perspective.

10) Physicians can learn from their patients' perspectives on their illnesses or problems. 11) Physicians should ask their patients why they think their illness has occurred. 12) Physicians should ask about how an illness is impacting a patient's life.

13) Physicians should make empathic statements about their patients' illnesses or problems. 14) Physicians should ask patients for their feelings about their illnesses or problems.

15) Physicians do not need to ask about patients’ personal lives or relationships to provide good health care.

Copyright 2002 by Martha A. Medrano, MD, MPH and Alison Dobbie, MD, the University of Texas Health Science Center at San Antonio. All rights reserved. Permission was granted from the authors to

APPENDIX C: Communicating Between Cultures

The point of this exercise is to appreciate cultural differences instead of hiding from them or fearing conflict. Have the class view the video Communicating between Cultures (Schrank & Diffenbach, 2004) together and then divide into small groups to respond to the following

questions. The key to these discussions is to keep an open mind and to see the situation from the other person’s point of view rather than to pass judgment on the culture. It is important to stress during discussion that it is unlikely that the average person would remember a long list of cultural differences. Instead we need to be aware that cultural differences exist and often explain what seems to be illogical or even rude behavior. It is unrealistic to expect a person to know the multitude of cultural values and differences in the world. For each of the vignettes on the video have students respond to these questions:

o Glassland

1. What is the meaning of Glasslands?

2. What is meant by the “built in eye glasses?”

3. Imagine you are transported to Glasslands today with no built in eye glasses. How would you be received by Glasslanders if your message were that “it’s time to remove your glasses and see the world as it really is?”

o Fred the Gardner

1. Is Fred merely too quick to judge or is he prejudiced?

2. Why does the video show BOTH Fred and Jose wearing sunglasses? o Lee knows Chinese Food

1. Is this situation an example of ethnic discrimination? o Language

1. How do you feel in the presence of a conversation you do not understand? 2. Do you feel differently if you perceive that the conversation is ABOUT you? 3. Comment on this statement: “…Americans think English, French, and Irish

accents are cute and charming. But they don’t find Asian accents as attractive.” Is this prejudice or truth?

o Direct vs. Indirect

1. Say what you mean, get right to the point, and speak your mind are American virtues. How is this different from other cultures that view social harmony as more important?

2. How does this work when Jared asks Tabore for a ride?

3. How could this affect patient care…or the clinical instructor/student relationship? o Kim is offered help

1. Is Mike giving Kim a brush off or is there a cultural misunderstanding here? 2. Why does Kim seem hurt by the fact that Mike won’t help now?

o Illya lands a job

1. What cultural difference caused the confusion in this example? 2. What is the assumption Brianna has made?

o Frishta and Alex

1. Should Alex have known NOT to offer Frishta a high five?

2. What is the best way to approach or respond to a similar situation (ever have a pt, who wants to hug and kiss you?)

APPENDIX D: DPT Clinical Case Outline

Using the Guide to Physical Therapist Practice

You must complete 3 cases. Please have them complete and ready to present at the start of the semester, following your prior clinical experience

One case should be a multi-system (at least 2 co-morbidities); one case should involve at least 2 health care team members (i.e. PT, OT, or SLP); and one case must involve a patient with a culture that is different from yours.

Student’s Name: Facility Attended:

Practice Pattern/System: Pattern: ICD-9-CM Code:

I. EXAMINATION: Patient/Client History Systems Review Tests and Measures II. EVALUATION: Clinical Judgment

Impairments/Problems

III. DIAGNOSIS: Primary dysfunction

Secondary/tertiary dysfunction

IV. PROGNOSIS: Amount of rehab time

Goals/objectives

Plan of Care

V. INTERVENTION: Coordination, Communication, Documentation

Therapeutic Exercise

Functional Training

Manual Therapy

Devices and Equipment

Physical Agents

VI: OUTCOMES: Re-evaluation

APPENDIX E: Case Presentation

You are to pick two cases from either of your clinical experiences. You will have a total of 35-40 minutes to present each case. The presentation must consist of 2 parts: a small group presentation (lecture/information) and small group interaction. You may divide the allotted 35-40 minutes between the two parts as you see fit.

A. Small Group Presentation:

Part of the case will be presented to the entire group. This presentation will take place in your small group of three students. You should use handouts or other supportive material (pictures represent a 1,000 words!). This presentation will be assessed, by a randomly chosen classmate in your small group, based upon your presentation style, completeness, interest, educational content and your learning experience. Since you will probably only use 15 minutes to present, you must emphasize only a few points about the case that you think will be particularly interesting or helpful to your classmates. You should, however, include enough information for all to grasp the case. Be as creative as you wish.

B. Small Group Interaction:

The second part of the case is to be presented in your same small group of 3. The guidelines are wide-open. You may give a written copy of a case with some things left off and have groups fill in the blanks, or you can provide a case and have your peers answer different or same questions. Try to ask “good” questions that stimulate thought and discussion, such as, “How could the patient’s practice of visiting a faith healer affect his outcomes?” Avoid questions like, “What would the short term goals be?” You could have the group do written work to hand in or give your peers 5-7 minutes to work on several discussion points and then report back to entire group. Again, be as creative as you can and think deeply.

APPENDIX F: Measuring Integration

Patient

question “Why does the pain feel different in my neck, shoulder, arm and hand?” Student response Satisfactory

3

Marginal 1.5

Unsatisfactory 0

To explain normal physiologic or biomechanical mechanisms.

Good explanation, in a manner understood by the patient, uses model or visual image, talks about structures in the cervical spine referring the pain.

Explanation not clear or not supported by visuals, language does not match the patient’s level of understanding.

Disregards question, confusing explanation, language confuses the patient.

Patient

question “When you were doing testing, why does it hurt when I tilt my head to the (L) side?”

Student response Satisfactory 3 Marginal 1.5 Unsatisfactory 0 To explain abnormal physiological or biomechanical mechanism

Good explanation, talks about compression on nn root and spinal structures. May use model or visual image, in a manner likely understood by the patient.

Explanation not clear or not supported by visuals, language does not match the patient’s level of understanding.

Disregards question, Confusing explanation, language confuses the patient.

Patient

question “Members of my family have used spiritual healers in Puerto Rico; do you think I should try one?”

Student response Satisfactory 3 Marginal 1.5 Unsatisfactory 0 To discuss prognosis, the role

of intervention/ Prevention or 2 complications

Explains that the PT can work with a spiritual healer and that they are interested in learning more about the practices so that it can be an adjunct to the PT program.

May show some support for pts beliefs but appears skeptical and attempts to sway patient away from using a spiritual healer.

Does not support patient’s beliefs or talk about other therapy interventions. Disregards patient’s question.

States spiritual healing has no evidence to support its efficacy.